These are statements that many people have used to describe their voices and the effects
of their voices on their lives. Please circle the response that indicates how frequently you have the
same experience.
The Composite of these scores should be 10 or below. If it is more than 10, you should consider an
evaluation to check for “Silent Gastroesophageal Reflux Disease, “ or GERD.
Within the last MONTH, how did the following problems affect you?

0 = No problem
5 = Severe problem

Name

FirstLast

Email

Phone

Hoarseness or a problem with your voice

0

1

2

3

4

5

Clearing your throat

0

1

2

3

4

5

Excess throat mucous

0

1

2

3

4

5

Difficulty swallowing food, liquids or pills

0

1

2

3

4

5

Coughing after eating or lying down

0

1

2

3

4

5

Breathing difficulties or choking episodes

0

1

2

3

4

5

Troublesome or annoying cough

0

1

2

3

4

5

Sensations of something sticking in your throat or a lump in your throat

0

1

2

3

4

5

Heartburn, chest pain, indigestion, or stomach acid coming up

0

1

2

3

4

5

Total

It is likely that you do not have a reflux condition. However, if you believe you still have severe symptoms please- request an appointment or call our office at 212-889-8575